Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

Abstract

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

Insight into the da Vinci® Xi – technical notes for single‐docking left‐sided colorectal procedures

“…Reflecting the learning curve inherent to the adoption of a new technology, several authors have described a shortening of docking time with experience . Various authors have also described dual‐docking and single‐stage docking techniques aimed at maximizing the working field of the robot …”

Robotic single docking total colectomy for ulcerative colitis: First experience with a novel technique

“…There are different assessed advantages of the robotic system over the traditional laparoscopic approach, like a stable and magnified 3D HD view or the possibility of using various and multi-articulated endoscopic instruments (Endowrist ® System). These features allow the surgeon to better identify anatomic structures and increase the freedom of movements inside the abdominal cavity [18]. This is particularly true in some surgical procedures that require a special dexterity of the laparoscopic surgeon, such as total colectomies.…”

“…In fact in this procedure the robotic cart needs to be docked two times, one for the splenic flexure mobilization and the other for the total mesorectal resection. Several surgeons have tried different techniques to overcome the challenge of performing a low anterior resection with total mesorectal excision and splenic flexure mobilization using the da Vinci robotic system [18,19,25]. Obias et al [26] adopted the 'flip arm' technique, which utilizes all three robotic arms throughout the procedure and keeps the patient-side cart docked only once.…”

Applications and Economics Aspects of Robotic Surgery

“…Robotic surgery is seen as a promise in several surgical areas, as there is no strong scientific evidence demonstrating increased [3]. Precise dissections provide fewer complications related to erectile dysfunction in postoperative of total mesorectum resection in rectal cancer surgery after 3 months of surgery.…”

“…It is estimated that only 10% of colorectal cancer surgeries are currently treated by laparoscopy, with increasingly use of robotic platforms added to the perspective of visualization improvement, exposure and dissection of important structures in narrow space, such as the pelvic cavity. Besides all that, the great mobility of instruments, capable to rotate from 180° to 540° allows better performance in the pelvic cavity [3]. There are even better results in the quality of oncological resection with clearer margins, higher number of lymph nodes resection and decrement of surgical complications as the learning curve is exceeded…”